A Multicomponent Primary-Care Intervention for Preventing Falls in Older Adults Living in the Community: The PREMIO Study.

BACKGROUND: Falls are a common cause of morbidity and functional impairment in the elderly and represent a significant health problem. General practitioners (GPs) are the first point of contact for health issues and may provide preventive services. The randomized clinical trial PREMIO was conducted by GPs to evaluate the effects of a multicomponent intervention for the prevention of falls in older adults aged ≥ 65 years at high risk of falling. METHODS: 117 GPs enrolled 1757 patients (1116 F, 641 M) and randomized them into 2 groups (intervention and control). The intervention group received medical and behavioral counseling, home risk-factor assessment, a physical-activity program and nutritional counseling. The control group received only the nutritional counseling. Both groups were followed for one year. The primary outcome was the rate of falls at home over 12 months. RESULTS: 1225 patients completed the study. Subjects receiving the intervention had, on average, fewer falls at home (percentage change -31.2%, p < 0.02) and fewer total falls (-26.0%, p < 0.02), although the reduction in the number of fallers was small (-3.9%, p = 0.05). Among the secondary endpoints, rates of general hospital or emergency-department admission and GP visits showed slight improvements (not statistically significant), while the risk of fractures was unexpectedly increased in the intervention group compared to the controls (odds ratio 2.39, p = 0.023). CONCLUSIONS: Future studies and public-health interventions to prevent domestic falls among community-dwelling older people at high risk of falling could benefit from a multicomponent approach including medication review, physical exercise and home risk assessment and should include assessment of risk factors for fractures.

The impact of anatomic, patient and surgical factors on membrane perforation during lateral wall sinus floor elevation.

OBJECTIVES: This retrospective study aimed to evaluate the influence of anatomical, patient and surgical factors on the occurrence of membrane perforation (MP) during lateral window sinus floor elevation (LWSFE). MATERIAL AND METHODS: A review of LWSFE patient records between 2014 and 2019 accounted for MP occurrence, window surface area (WSA), intravenous sedation use, osteotomy instrument type and clinician experience. Preoperative cone beam computed tomography (CBCT) scans were analyzed for lateral wall thickness (LWT), LFM and LAM angles formed between lateral and medial walls at the floor and anterior wall, respectively, sinus width at 5-, 10- and 15-mm (LM-5, LM-10 and LM-15) from the floor, residual bone height (RBH), sinus pathologies, septa and arterial anastomoses. The generalized estimating equation (GEE) approach with a sandwich variance-covariance estimator was used to evaluate the associations with MP. RESULTS: MP occurred in 25.74% of 202 LWSFE procedures (166 patients). Mean 1.6 mm-LWT, 3.2 mm-RBH, 95°-LFM, 75.5°-LAM, 12 mm-LM-5, 20.79% septa, 16.83% arterial anastomosis, 37.62% sinus pathology and 29.21% intravenous sedations, 85.24% WSA ≥ 40 mm2 and 57% >10 procedures/clinician were reported. Greater MP rates were encountered as follows: 38.3% (LWT ≥ 1.5 mm), 38% (LFM < 90°), 59.6% (LAM < 70°), 45.4% (LM-5 < 10 mm) and 36.4% (WSA ranged > 80 mm2 ), with statistically significant associations with all these outcomes (p < .05). The presence of pathologies was also associated with MP (p = .013). Associations between MP and the presence of septa and arterial anastomoses, age/gender, right/left sinus, RBH, clinician's experience, instrument type and intravenous sedation use could not be demonstrated. CONCLUSIONS: MP is significantly associated with thicker lateral walls, narrower sinuses, larger windows and existing sinus pathology.

The prophylaxis of venous thromboembolism in medical outpatients: results of a survey among italian general practitioners.

BACKGROUND: Although the majority of venous thromboembolic events occurs in primary care, most of the studies concerning its prophylaxis investigate hospitalized patients. Therefore, in primary care, many clinical decisions have to be taken in the absence of great clinical evidence derived from studies performed directly on outpatients. The objective of our study is to evaluate the clinical approach of Italian General Practitioners to the prophylaxis of venous thromboembolism in medical outpatients. METHODS: A web-based questionnaire was emailed to 766 Italian General Practitioners. In the questionnaire there were four exemplary clinical cases concerning hypothetical patients at venous thromboembolic risk. RESULTS: Overall 232 questionnaires were returned. Approximately 40% of the participants reported to assess thrombotic and hemorrhagic risk with a risk assessment model but nevertheless only a narrow minority had recourse to a suitable and validated score for this purpose. In the chronically bedridden patient about half of the participants administered a heparin or an antiplatelet drug for long time. In acute outpatients at high venous thromboembolic risk there was a considerable underuse of heparin prophylaxis and graduated compression stockings were often considered as a first prophylactic option. Prolonged heparin prophylaxis in the post-acute setting was also the practice for half of the participants. CONCLUSIONS: Italian General Practitioners approach these "grey" areas of uncertainty in a significantly heterogeneous way and sometimes in sharp contrast to the recent evidence.  The present findings stress the need for further targeted educational programs and new high quality studies to further deep this clinical context.

Toward uniform and controlled clinical pathways in cancer care: a qualitative description.

QUALITY ISSUE: The definition of clinical pathways (CPs) and their application are heterogeneous. Each center is used to choose whether to adopt this instrument or not and to variably conceive its features We consider CPs as the necessary description of the cancer patient journey and we emphasize their role as the user view of clinical processes rather than a local translation of guidelines. CHOICE OF SOLUTION: We proposed a unique CPs model for all the centers of our regional network, with the aim of making CPs accountable and comparable. We also established a central quality evaluation. IMPLEMENTATION: Through a multi-step process, the model was proposed to the 22 Regional centers. Landmark characteristics of the project were: the involvement of hospital administrations; reference to a unique set of guidelines; a peer-review and open evaluation. EVALUATION: Of the 374 expected CPs, 253 (68%) were received and evaluated. A median number of 131 items were the object of evaluation in each hub center and 77 in each spoke center. About 79.5% items were considered well described, 15.5% were absent and 5.0% partially described. The median percentage of fulfilled indicators was 85.6% in hub CPs and 82.2% in spoke CPs. Although, not all diseases were equally covered through the territory a high degree of homogeneity and a good quality of compilation were achieved. LESSONS LEARNED: The project was shown to be feasible and achieved its goal. We suggest this process as a functional way for building uniform cancer CPs.

Recommendations for the implementation of international standardization of glycated hemoglobin in Italy.

This document is issued by the Italian Society of Clinical Biochemistry and Clinical Molecular Biology (SIBioC) and a number of other National Scientific Societies and Associations in order to promote a coordinated plan for implementing the standardization of glycated hemoglobin (HbA(1c)) measurement in Italy according to the recommendations by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). Changes in reporting HbA(1c) results, new units, how to relate old and new units, a timeline for changes and definition of the analytical goals are the main issues discussed.